Module 8
The nurse is performing an assessment on a toddler and observes a protuberant abdomen. What is the significance of this finding?
This is a normal finding for a toddler.
A pregnant client comes in for a routine visit and tells the nurse that she is concerned with the frequent nosebleeds that she is experiencing. What should the nurse inform her about these nosebleeds?
"Nosebleeds are common in pregnancy and caused by capillary rupture from increased progesterone." R: During pregnancy, capillaries with lax walls proliferate from increased production of progesterone by the placenta. Epistaxis (nosebleeds) are a common result.
The prenatal client expresses concern about the appearance of raised bumps on her areola. What is the best response by the nurse?
"Small glands on your areola have enlarged in preparation for breastfeeding." R: The Montgomery tubercles are sebaceous glands on the areola that enlarge during pregnancy. They produce an oily secretion that lubricates and protects the nipple, especially important for breastfeeding women.
A client who is 32 weeks' gestation tells the nurse that she has been experiencing shortness of breath when walking up the steps at home. She is concerned that something is wrong. What is the nurse's best response?
"The enlarging uterus pushes against your diaphragm, and this makes breathing shallow." R: Increasing levels of progesterone cause relaxation of ligaments and joints. This allows the rib cage to flare to accommodate the enlarging uterus. As the uterus enlarges, it pushes up against the diaphragm. This changes respirations from abdominal to costal, causing the woman to feel short of breath.
A new mother tells the nurse that the newborn has a small yellow lesion on the hard palate of the mouth and is worried about the baby's ability to suck properly. What should the nurse tell the mother about this finding?
"This is common and will disappear within the first few weeks." R: This finding is common in newborns and is called an Epstein pearl. It is found on the hard palate and gums and presents as a small, yellow-white retention cyst that disappears within the first few weeks of life. Sucking tubercles are common in infants on the upper lip but do not occur from improper sucking.
What question should the nurse ask in order to assess an adolescent's risk factors for obesity and deficient nutritional status?
"What do you eat in a typical day?" R: Describe what you eat on an average day. Overweight and obesity have serious health consequences among children and adolescents, including a greater risk of high cholesterol, hypertension, and diabetes mellitus.
The nurse has been asked to perform a stereognosis test on an adult client. Which instructions should the nurse provide to the client before performing the test?
"With your eyes closed, identify the object I place in your hand." R: Stereognosis is the ability to identify objects correctly by touch to test the sensory cortex. Graphesthesia is the ability to correctly identify a number traced on the skin. Coordination is tested with rapid alternating movements and the finger to nose tests.
The 22-week prenatal client states, "I feel a pulling type of pain around my belly button." Which is the best initial response by the nurse?
"Your body is stretching as the baby grows." R: Women commonly report a stretching pain around the umbilicus about halfway through the pregnancy as the uterus grows and stretches ligaments.
While caring for a pregnant client at 8 weeks' gestation, the client asks the nurse, "When can you hear the baby's heartbeat?" The nurse should instruct the client that when a Doppler device is used, the earliest time when the fetal heart rate can be heard is the gestational age of
10 weeks. R: A fetal Doppler ultrasound device can be used after 10-12 weeks' gestation to hear the fetal heartbeat.
A mother brings her 12-year-old son to the clinic for a routine physical. The mother tells the nurse that her son seems to be growing taller recently. The nurse should instruct the mother that the peak growth spurt in boys usually occurs by age
14 years. R: Growth spurt usually peaks at 12 years in girls and 14 years in boys.
The nurse is preparing to auscultate heart sounds on an 8 year old. Where would the nurse anticipate the point of maximal intensity (PMI)?
5th intercostal space R: The PMI is at the midclavicular line (MCL) in infancy and moves slightly laterally with age to the 4th intercostal space just to the left of the MCL in children younger than 7 years of age, and then to the 5th intercostal space in children older than 7 years of age.
Upon delivery the newborn is crying; moving; has a heart rate of 146; respiratory rate is slow and irregular; and is cyanotic. What Apgar score would the nurse assign to this newborn?
7 R: The newborn is crying (2); moving (2); has a heart rate of 146 (2); respiratory rate is slow; and irregular (1); and cyanotic (0) for an Apgar score of 7.
Which action by the nurse demonstrates the correct technique to elicit Ortolani's maneuver?
Abduct the legs and move the knees outward R: The nurse should abduct the legs and move the knees outward to elicit Ortolani's maneuver. Barlow's maneuver involves adducting the legs until the thumbs of the nurse touch. Assessing the symmetry of the gluteal fold is done to look for hip dysplasia but is not a part of Ortolani's maneuver. The buttocks are spread with gloved hands to examine the anus.
How do many older adults define their health?
Ability to function independently R: Many older adults define their health by their ability to perform self-care, which health care providers identify as functional abilities. Functional ability in an older adult can vary widely during his or her later years.
The triage nurse is assessing a 7 year old child brought to the emergency department complaining of abdominal pain. Which findings would prompt the nurse to have the child evaluated as soon as possible? (Select all that apply.)
Acute intense pain with vomiting Child isolates pain in right lower quadrant Child unable to stand due to pain R: Children usually cannot isolate abdominal pain to one specific area. If the child points to the right lower quadrant, appendicitis should be ruled out with abdominal scans. Acute intense pain with vomiting may indicate appendicitis. A child who stops activity or plan because of pain requires additional evaluation. If rest relieves the pain, life-threatening concerns are usually not the problem.
A nurse should implement which important criterion to promote an effective nurse-parent communication when conducting a parent interview as a part of the child assessment?
Allow privacy for interview R: To promote an effective nurse-parent communication, the nurse should allow privacy for the interview. The nurse should also use interpreters in case of language difference and allow adequate time for the interview. The nurse should keep interruptions to a minimum.
A young child refuses to allow a nurse to palpate the abdomen because it tickles. How can the nurse decrease the child's ticklishness to facilitate completion of the exam?
Allow the child to place the hand under the examiner's hand R: To decrease ticklishness, have the child help by placing the hand under the nurse's hand, using age-appropriate distraction and conversation focused on something other than the exam.
The nurse should intervene when observing which parental action as a child is placed in a motor vehicle leaving the hospital?
An infant is placed in a forward facing car seat.
A nurse is examining the sacrum and coccyx of a client in her third trimester of pregnancy. Which of the following findings would increase this client's risk of cesarean delivery? Select all that apply.
Anthropoid pelvis Platypelloid pelvis R: An anthropoid or platypelloid pelvis with an immobile coccyx may interfere with vaginal birth. This type of pelvis may increase the risk of cesarean delivery. A gynecoid pelvis is most common. A mobile coccyx increases ease of delivery by expansion, enlarging the area in the pelvis. Obstetric conjugate is normally between 12 and 13 cm in adult women.
A nurse assigns an Apgar score to a newborn baby at 5 minutes after delivery. Which parameter should the nurse recognize as an abnormal finding?
Apical pulse is less than 100 beats per minute R: A newborn's heart rate ranges from 120 to 160 beats per minute until about 6 months of age. A heart rate less than 100 beats per minute is abnormal, and the nurse needs to further assess the newborn.
A nurse at the health care facility assesses a client in the 20th week of gestation. The client is healthy and progressing well, without any sign of complications. Where should the nurse expect to measure the fundal height in this client?
At the level of the umbilicus R: In the 20th week of gestation, the nurse should expect to find the fundus at the level of the umbilicus. The nurse should palpate at the top of the symphysis pubis between 10 and 12 weeks' gestation. At 16 weeks' gestation, the fundus should reach halfway between the symphysis pubis and the umbilicus. With a full-term pregnancy, the fundus should reach the xiphoid process.
A mother of a 4 year old child calls the clinic nurse because her child has swallowed some type of cleaning agent. What is the nurse's best response?
Call the Poison Help Line #1-800-222-1222 for instructions on treatment. R: The American Association of Poison Control Centers (AAPCC, n.d.) provides information needed for the home or hospital treatment of a child who has ingested a toxic substance. The Poison Help Line number is 1-800-222-1222. Recommendations might include use of ipecac syrup, activated charcoal, or both. Parents can buy these medications without a prescription; however, they should be used only when instructed to do so by the AAPCC. Currently, these medications are not recommended for home use because they have been used inappropriately in the past.
A 26-year-old telephone operator comes to the office for her first prenatal visit. This is her first pregnancy. Her last menstrual period was approximately 2 months ago. She has no current complaints. She is eating healthy, taking vitamins, and exercising. She has a past medical history of an appendectomy as a teenager. Her mother had three children vaginally with no complications. On examination the client appears healthy. Vital signs and head, eyes, ears, nose, throat, thyroid, cardiac, pulmonary, and abdominal examinations are unremarkable. Speculum examination shows a cervix bluish in color and highly vascular. Bimanual examination reveals a soft cervix and a 12-week-sized uterus. No masses are palpable in either adnexal area. Her Pap smear, cultures, and blood work are pending. What clinical sign is responsible for her blue highly vascular cervix?
Chadwick's sign R: Chadwick's sign is observed during speculum examination when the cervix appears more vascular and takes on a bluish hue. It can also occur with ectopic pregnancy.
A 12 year old adolescent female presents to the clinic alone requesting birth control and testing and treatment suspected chlamydia. What is the nurse's priority action?
Check state regulations about testing and treatment of minors. R: Most states permit contraception and treatment for sexually transmitted infections at 13 years of age; therefore the nurse should first check state regulations regarding a 12 year old seeking treatment before collecting urine sample or cervical exam is performed.
A nurse assesses a primigravida client in the eighth week of gestation. The client reports nausea and vomiting in the mornings. The client expresses concerns about hormonal changes that would affect her physical appearance. Which client concern should the nurse assess first?
Deficient fluid volume R: The nurse should identify deficient fluid volume as a risk that needs immediate attention. The client may be at risk for hyperemesis gravidarum if she is dehydrated.
It is summer and an 82-year-old woman arrives at the emergency room from her home after seeing her primary care physician 2 days ago, when she had been started on an antibiotic. Today, she does not know where she is or what year it is. What could be a likely cause?
Delirium R: the combination of the heat and a recent infection make delirium much more likely.
The nurse identifies the need to assess a child's motor, language and social development. What test would be most appropriate?
Denver Developmental Screening R: The Denver Developmental Screening Test is used for the developmental evaluation of children aged 1 month to 6 years. It evaluates personal/social, language, fine and gross motor skills. Blackboard and Hirschberg are vision screening exams.
Which finding should cause a nurse concern if found on the interview of a school-age child?
Displays difficulty in reading simple sentences R: By the time a child reaches school age, the ability to read is the most significant skill learned during these years.
A nurse notes the respiratory rate of a 2-year-old to be 28 breaths per minute. What is an appropriate action by the nurse in regards to this finding?
Document the finding in the child's chart R: The normal respiratory rate for a child between the ages of 2 and 10 is 20 to 28 breaths per minute. The nurse should record this normal finding in the child's chart.
The nurse has assessed and informed the healthcare provider of a brown-colored lesion on an older client's left cheek. The lesion is diagnosed as solar lentigines. What is the nurse's best action?
Encourage the client to wear sunscreen daily. R: Sun exposure causes solar lentigines, a benign skin lesion also known as age or liver spots. Usually these lesions are diagnosed by appearance and biopsy is not necessary.
The nurse notes dull lung percussion along the lower right lobe of an adult client. Which intervention should the nurse initiate right away for this client?
Encourage turning, coughing, and deep breathing. R: Dull lung percussion indicates increased consolidation as with pneumonia. Encouraging turning, coughing, and deep breathing is the only independent nursing intervention that can be begun right away.
A client who is 37 years of age presents to the health care clinic for her first prenatal check up. Due to her advanced age, the nurse should prepare to talk with the client about her increased risk for what complication?
Genetic disorders R: Women over the age of 35 are at increased risk of having a fetus with an abnormal karyotype or other genetic disorders. Gestational diabetes, an incompetent cervix, and preterm labor are risks for any pregnant woman.
Due to the risk of fetal transmission, pregnant mothers should be screened for what disease?
Hepatitis R: Hepatitis can be transmitted from the mother to the fetus. Newborns of positive mothers are given an HBIG (IgG antibodies) injection and are immunized against hepatitis B shortly after birth.
A new mother wants to give her baby honey. The nurse tells her that it is potentially dangerous to do this. Why is this practice potentially dangerous?
Honey is a known reservoir for the botulism bacterium R: Honey should not be given to infants. It is a known reservoir for the bacterium that causes botulism. The spores that the bacteria produce make a toxin that can cause infant botulism, a serious form of food poisoning. The toxin affects the infant's neurologic system and can lead to death.
On assessing a newborn, a nurse observes a separation of the abdominal muscles. That nurse recognizes the underlying case of this condition is which of the following?
Immature abdominal muscles R: Diastasis recti (separation of the abdominal muscles) is seen as a midline protrusion from the xiphoid to the umbilicus or pubis symphysis. This condition is secondary to immature abdominal muscles and usually has little significance.
A nurse inspects the anus of a newborn. Which of the following findings should be referred immediately to a specialist?
Imperforate anus R: Imperforate anus (no anal opening) should be referred. The anal opening should be visible and moist. Perianal skin should be smooth and free of lesions. Perianal skin tags may be noted. No passage of meconium stool could indicate a lack of patency of anus or cystic fibrosis. Meconium is passed within 24 to 48 hours after birth. Pustules may indicate secondary infection of diaper rash.
A mother brings her 2-month-old infant to the health care facility with a high temperature. Which action by the nurse demonstrates the proper way to safely measure the rectal temperature in the baby?
Insert the thermometer no more than 2 cm into the rectum R: The rectal temperature is most accurate. The nurse should insert the lubricated rectal thermometer no more than 2 cm into the rectum when taking the rectal temperature. The baby should be in the supine position and not in the prone position when assessing rectal temperature. The newborn's legs should be bent at the hip, not at the knees. Temperature registers in 3 to 5 minutes, not 1 minute, on a rectal thermometer.
The mother of an 8 year old girl expresses concern about feeling a lump at each of the child's areolas. What is the nurse's best response?
It is likely a breast bud which is a normal finding at this age. R: Breast development begins with a "breast bud" or enlargement of the areola followed by enlargement of breast tissue. The onset of pubertal changes before 8 years in girls and 9 years in boys may be too early and needs further evaluation.
A nurse should assist an elderly client to assume which position to facilitate the examination of the anus and rectum?
Left side-lying R: The anus and rectum should be assessed with the client in left side-lying position for better accessibility and comfort.
A client in her third trimester of pregnancy is undergoing a physical assessment. Her nurse explains that she is about to estimate what position the fetus is presently in by palpating the uterine fundus to see whether the head or buttocks is presenting. What is this procedure called?
Leopold's maneuver R: Leopold's maneuvers are performed to determine the position of the fetus and determine whether the fundus contains the head or the buttocks. The head moves independently of the torso but the buttocks do not.
A mother brings her 3-month-old infant to the health care clinic because she has noticed that her child has developed a sunken abdomen with prominent rib cage. That nurse recognizes the underlying case of this condition is which of the following?
Malnutrition and dehydration R: A scaphoid (boat-shaped; i.e., sunken with prominent rib cage) abdomen may result from malnutrition or dehydration.
Which of the following indicates that an elderly client has been affected by polypharmacy?
Medications are used to counteract side effects of other prescribed medications. R: Older adults live with one or more chronic conditions, which often results in a complex medication regimen. Older adults are at risk for adverse medications due to the numerous medications they may be taking. Side effects of one medication may necessitate another medication to manage the side effects. Consequently, older adults experience polypharmacy.
The nurse has completed examining the client's nose and sinuses. Which body area should the nurse examine next?
Mouth and pharynx R: If following a head-to-toe examination approach, the nurse should examine the client's mouth and pharynx after examining the nose and sinuses. The neck is done after assessing the mouth and pharynx. The posterior thorax is examined after the neck. The anterior thorax is examined after the posterior thorax.
Which procedure demonstrates correct placement of a tape measure by a nurse when measuring the chest circumference of a 12-month-old infant?
Nipple line
The nurse is assessing a pregnant female in the outpatient clinic. The client exhibits a fever and complains of having flank pain for the past two days. What is the nurse's priority action?
Notify the healthcare provider. R: A condition in pregnancy requiring immediate attention is pyelonephritis, which occurs when a urinary tract infection is not treated promptly. Because the immune system does not fight infections as well during pregnancy, a bladder infection can quickly become a kidney infection, which is characterized by severe flank pain and a fever. Although the nonpregnant client with pyelonephritis is often treated on an outpatient basis, during pregnancy pyelonephritis require intravenous antibiotics immediately to prevent generalized sepsis, which is potentially fatal. Based on the client's symptoms, the nurse should notify the healthcare provider right away before an antipyretic is administered or before obtaining blood cultures, if cultures are necessary.
A nurse is caring for a client who uses a hearing aid for amplifying sound. During the Rinne test for checking bone conduction of the sound, where should the nurse place the stem of the tuning fork?
On the mastoid area. R: The nurse should place the stem of the vibrating tuning fork on the mastoid area behind the ear to test for bone conduction of sound waves in the tested ear. The stem is placed in the center of the head to determine equality or disparity of bone-conducted sound when conducting Weber's test.
The nurse is preparing to perform an assessment on a toddler. Where should the nurse position the child?
On the parent's lap R: A toddler can remain in the parent's lap to decrease anxiety. An examination table may increase anxiety, a stool is not safe and a toddler will not remain inactive long enough to stand
The nurse is seeing a client with a recent history of exposure to a family member who has influenza. The client reports a throbbing toothache when bending forward. Which assessment should the nurse be sure to include in the physical examination?
Palpation of the sinuses R: A recent exposure to a family member with influenza along with the complaint of a throbbing toothache when the client bends forward should cue the nurse to assess for acute sinusitis. The assessment should include palpation of the sinuses.
A client who is pregnant presents to the health care clinic for a routine checkup. She tells the nurse that her hands have been tingling over the past 2 weeks and they often become numb at night. What assessment should the nurse perform to obtain data in regards to this subjective information?
Perform the Phalen's test R: The client's symptoms are suggestive of carpal tunnel syndrome, a common occurrence in pregnancy due to retention of fluid that causes swelling and compression of the median nerve. Phalen's test is used to confirm this condition. Range of motion tests joint mobility. Palpation of the anatomic snuffbox is done if there is a suspected fracture of the scaphoid. Heberden's nodes are seen in osteoarthritis.
In assessing a client who is in her second trimester, a nurse observes that the client is underweight and anemic from lack of dietary iron. The nurse suspects malnutrition and asks the client about her diet and eating habits. The client confesses that she has been craving and eating clay recently. The nurse recognizes this condition as which of the following?
Pica R: Pica, a craving for or ingestion of nonnutritional substances such as dirt or clay, is seen in all socioeconomic classes and cultures. Pica can be a major concern if the craving interferes with proper nutrition during pregnancy.
A pre-teen client has been admitted to the pediatric unit with bilateral lower lobe pneumonia. When writing a plan of care for this client, what would be the most appropriate intervention?
Provide information that contributes to an improved state of health R: The most pertinent intervention is to provide information that contributes to an improved state of health. Parenting would be assessed throughout childhood but is not the most appropriate intervention for a pre-teen client with pneumonia. Age-appropriate community activities are not a concern for a client with a respiratory infection.
A 26-year-old flight attendant comes in for a third-trimester visit. She has had prenatal care since her sixth week of pregnancy. She has no complaints today, and her prenatal course has been unremarkable. Today her blood pressure and weight gain are appropriate and her urine is unremarkable. A first-year student is shadowing the visit, so the nurse asks the student to get Doptones and measure the client's uterus in centimeters. The student promptly reports fetal heart tones of 140 but is having difficulty obtaining the correct measurement. The student knows that one end of the tape goes over the uterine fundus. From what inferior anatomical position should the tape be placed?
Pubic symphysis R: In most women, measuring from the symphysis to the uterine fundus is approximately the same and very predictable for dating purposes.
A child presents to the emergency department with nasal flaring and intercostal retractions. What is the nurse's priority intervention?
Raise head of bed and apply oxygen R: Children in physiological distress compensate with increased respiratory and heart rates. Physiological distress usually occurs from a respiratory disorder or significant blood loss. Children rarely present in acute distress from ischemic heart disease and resulting dysrhythmias. The child in respiratory distress presents with nasal flaring and chest retractions or abdominal breathing. Administration of oxygen and support of the child's ability to breathe are the first interventions. Then a medical history and list of medications can be obtained.
To obtain the most accurate temperature on an infant, a nurse should use which method?
Rectal R: A rectal temperature is the most accurate method for obtaining a temperature on an infant. Oral temperatures are not recommended until childhood when the child can understand the concept of holding the thermometer in the mouth.
During the health assessment interview, a nurse should ask the parents of a 9-year-old male questions related to which activities to elicit age-related development of psychosexual stage?
Relative sexual indifference and interaction with same-sex peers R: School-age children who are in the latency period of the psychosexual development stages have sexual indifference and tend to interact with same-sex peers.
During the breast exam of an elderly female client, which finding should a nurse recognize as a normal change associated with the aging process?
Retraction of the nipples R: Nipples retract in the elderly client due to loss of musculature. Unlike nipple retraction due to a mass, nipples retracted due to aging can be everted with gentle pressure.
A client visits the health care facility with reports of mild hearing loss. The nurse prepares to perform which test to compare bone and air conduction?
Rinne R: The nurse should perform Rinne test to compare between bone and air conduction in the client with mild hearing loss. Weber's test and audiometry are done to determine diminished hearing in one ear. The Whisper test is done to evaluate hearing.
A nurse assesses a newborn of African American descent and observes a bluish-pigmented area on the sacrum. The nurse recognizes this as what type of skin variation?
Slate gray nevus R: A bluish coloration of the skin on the sacral area is called a slate gray nevus and is common in infants of Asian, African American, Native American, and Mexican American descent. (Note: slate gray nevi were previously known as Mongolian spots.)
A nurse understands that which sleep pattern is considered normal for a preschooler?
Sleep 11 to 13 hours per day R: The average preschoolers sleep 11 to 13 hours per day. Preschoolers typically need an afternoon nap until the age of five. Preschoolers often do not sleep comfortably; sleep problems are common in them. School-aged children, not preschoolers, require only eight to nine and a half hours of sleep.
Which action by the nurse demonstrates the correct technique to assess the anus?
Spread the buttocks with gloved hands R: The buttocks are spread with gloved hands to examine the anus. The nurse should abduct the legs and move the knees outward to elicit Ortolani's maneuver. Barlow's maneuver involves adducting the legs until the thumbs of the nurse touch. Assessing the symmetry of the gluteal fold is done to look for hip dysplasia.
The client has been admitted with pneumonia. What should the nurse assess?
Sputum R: Swelling, heart tones and peripheral pulses are related to circulatory system The sputum of a client with pneumonia should be assessed.
During the admission assessment of a new client, the nurse is now preparing to assess the client's thyroid gland. How should the nurse perform this assessment?
Stand behind the client and palpate the sides of the trachea.
A nurse is preparing to perform the nurse's first complete assessment of a client at a hospital. Which of the following should the nurse consult to find out what can legally be assessed and diagnosed?
State's nurse practice act. R: Before performing a complete assessment, read your state's Nurse Practice Act to find out what you can legally assess and diagnose. Although it is also important to know hospital policy, it is the nurse practice act of the state in which you are practicing that determines what is legal for you to perform.
A pregnant client in her first trimester states, "I think I must be having a miscarriage. I have sharp pains in my lower abdomen sometimes!" What does the nurse understand is happening to this client?
The client is experiencing stretching of the round and broad ligaments. R: In the first trimester of pregnancy, sharp pains in the lower abdomen are common. Stretching of the round and broad ligaments that support the growing uterus causes them, which are usually very short and have a stabbing quality.
A young woman comes to the ED with lower abdominal pain on the right side and has been spotting blood for 2 days. She is diagnosed with an ectopic pregnancy, which is an obstetric emergency. An ectopic pregnancy is when what occurs?
The egg never leaves the fallopian tube R: Ectopic pregnancy occurs when the egg never leaves the fallopian tube. Signs of this potentially life-threatening condition include lower abdominal pain on one side and spotting of blood. Confirmation of ectopic pregnancy is considered an obstetric emergency requiring hospitalization and termination of the pregnancy to save the mother's life.
A nurse recognizes that which deep tendon reflex is absent in children until the age of 6?
Triceps
A mother is telling the nurse in a clinic that her family's former doctor told her that her 6-year-old has a venous hum. The nurse knows that this is considered a benign heart murmur at this age. t/f
True
A mother brings her 2-month-old infant to the health care clinic because she has noticed a bulge at the umbilicus that seems to get bigger when the baby cries. That nurse recognizes this as what type of finding?
Umbilical hernia R: A bulge in the abdomen at the umbilicus is an umbilical hernia. They are common in infants and usually disappear by one year of age.
The nurse suspects that a school-age child would benefit from a referral to a health care provider who specializes in the neurologic system. What did the nurse assess to make this clinical determination?
Unstable gait R: An abnormal neurologic finding in a school-age child is an unstable gait.
A nurse is documenting findings for an adolescent client. Which of the following should the nurse do?
Use a sequential approach R: Documentation for children and adolescents is the same as that for adults. Nurses document what they observe, palpate, percuss, and auscultate. Descriptions should be objective, accurate, and concise, yet comprehensive.
The nurse determines the heart rate of 100 beats per minute for a 5-year-old client as being:
Within normal limits R: The average heart rate of a 5-year-old client is 103 beats per minute, with the range being from 68 to 138 beats per minute.
The best approach to use when performing a total physical examination on a client is
a head to toe integrated assessment of body systems. R: A head-to-toe approach is more convenient for performing a comprehensive assessment, which integrates the assessment of all body systems. This approach conserves time and energy for both the client and nurse.
The nurse is preparing to assess a client's reflexes. At which point during the assessment should this be completed?
after assessing the motor function of the lower extremities R: Although many parts of the assessment can be completed at any time, assessment of the reflexes usually is completed after assessing the lower extremities and serves as a starting point for assessing neurologic functioning.
The nurse completes the health history of a 15-year-old client and the mother. What should the nurse do before beginning the physical examination?
ask the mother to leave the room R: Most adolescents older than 13 years prefer to be examined without a parent in the room. Not all adolescents are willing to put a gown so partially uncovering as the examination proceeds to preserve the client's modesty is important. The client may not want the mother to stay during the examination.
When you enter the room of a hospitalized client, the intravenous pump is alarming. The client is restless, moaning, crying, and exhibiting guarding behavior. An uneaten meal is sitting on the over-bed table; several family members are arguing loudly. What would be your priority?
assessing for pain R: Guarding is an indication of pain. This is the priority problem for the nurse to address.
The nurse is preparing to assess the fetal heart rate of a pregnant client near term. When the nurse hears the fetal heart rate above the maternal umbilicus, the fetus is most likely in which position?
breech. R: In breech presentations, fetal heart rate is heard in the upper quadrant of the maternal abdomen.
A client arrives to a healthcare facility for an initial appointment. Which type of assessment should the nurse expect to complete with this client?
complete R: A complete assessment is performed on new clients or new admissions to a health care agency. A focused assessment targets specific body systems.
A sign of infection in the elder that is more common than fever is
confusion.
An older adult client with type 2 diabetes reports leg pain. Which characteristic will assist the nurse in determining if this is persistent pain?
cramping legs for 3 months R: The time frame is important to consider when trying to determine if the pain is persistent. A 3-month history of leg cramping indicates the client is experiencing persistent pain.
The nurse is conducting a cephalic to caudal assessment with a newly admitted client. Why should the nurse compare findings from side to side?
determine symmetry R: A complete assessment is performed in a cephalic to caudal sequence comparing side to side for symmetry.
As pregnancy progresses, the abdominal muscles may stretch to the point of separation. This condition is termed
diastasis recti abdominis R: During pregnancy, the abdominal muscles stretch as the uterus enlarges. These muscles, known as the rectus abdominis muscles, may stretch to the point that permanent separation occurs. This condition is known as diastasis recti abdominis.
A gastrointestinal problem that often requires emergency treatment in the frail elder is
diverticulitis. R: If diverticula become infected, emergency treatment may be required to prevent perforation and sepsis.
The nurse is preparing to inspect a newborn's inner ear with an otoscope. The nurse should pull the pinna
down and back. R: Because an infant's external canal is short and straight, pull the pinna down and back.
The nurse is preparing to conduct an examination of a client's breasts and axilla. Which of the following equipment will the nurse need for this examination?
drape R: The nurse will need a drape to ensure for the client's privacy during the examination of the breasts and axilla.
While assessing the abdomen of a pregnant client, the nurse observes striae gravidarum. The nurse should instruct the client that after delivery, the striae gravidarum will
fade to a white or silvery color. R: Striae gravidarum, or stretch marks usually fade to a white or silvery color, but they typically never completely resolve after the pregnancy.
When supine, a client's knees do not touch the examination table. On what area should the nurse focus to learn more information about this finding?
flexion and extension R: Since the legs are not able to be completely extended, the nurse should focus on knee flexion and extension.
A client presents to the health care clinic for her first prenatal checkup. What nutritional supplement should the nurse discuss with the client to prevent neural tube defects in the developing fetus?
folic acid R: Pregnant women need to consume 400µg of folic acid to help prevent neural tube defects. This can be achieved by eating fruits, vegetables, fortified cereals, or a daily supplement. Routine supplementation of all other vitamins is based solely on needs assessment. Iron supplements are recommended to prevent iron deficient anemia.
During the assessment of a female client, which physical examination techniques should the nurse use to assess the vagina?
inspection R: The nurse should use the technique of inspection for assessment of the vagina. The nurse should insert the speculum and inspect the vagina for color, consistency, and discharge. Palpation is used for assessment of Bartholin's glands, the urethra, and Skene's glands. The transillumination technique is used to assess scrotal sac and the sinuses.
While assessing a 4-year-old child, the nurse observes that the child's nails are concave in shape. The nurse should assess the child for a deficiency of
iron. R: Concave shape, "spoon nails" (koilonychia) indicate iron deficiency anemia.
The nurse is caring for a client who is 24 weeks pregnant. The client tells the nurse that she has been secreting colostrum for the past few days. The nurse should instruct the client that colostrum secretion
is normal for some women in the second and third trimesters. R: Breast changes noted by many women include expression of colostrum in the second and third trimester.
While assessing the abdomen of a pregnant woman, the nurse observes a dark line from the client's umbilicus to the mons pubis. The nurse should explain to the client that this is called
linea nigra R: Hyperpigmentation also results from hormonal influences. It is most noted on the abdomen (linea nigra, a dark line extending from the umbilicus to the mons pubis).
While examining a client's head the nurse notes that several pieces of needed equipment are missing. Which item should be used to assess aspects of the ears and nose?
otoscope R: An otoscope can be used to assess both the ears and nose. The tip would need to be changed between the assessment of these areas.
A nurse assesses a primigravida client and observes a pinkish color on the palms of the hands. How should the nurse document this pigmentation?
palmar erythema R: Palmar erythema is a pinkish color on the palms of the hands that often occurs during pregnancy.
When assessing the abdomen, which assessment technique is used last?
palpation R: The sequence of techniques used to assess the abdomen is inspection, auscultation, percussion, and palpation. Percussion and palpation stimulate bowel sounds and thus are done after auscultation of the abdomen.
While communicating with an ill 5-year-old child, one of the most valuable communication techniques that the nurse can use is
play. R: Play is one of the most valuable communication techniques when working with children; it allows for the discovery of important clues to children's development and illness behaviors.
A primigravida presents to the clinic with headache and proteinuria. The nurse obtains a blood pressure of 180/110 and suspects the client is suffering from:
preeclampsia R: Clinical manifestations of preeclampsia include significantly increased hypertension, persistent headache, malaise, sudden edema, especially of the face, and proteinuria 1+ or greater.
A young mother visits the clinic with her 18-month-old child. The mother asks the nurse when she should begin toilet training with the child. The nurse should explain to the mother that
she can begin bowel training as soon as the child appears ready. R: Toilet training is a major task of toddlerhood. Readiness is not usual until 18 to 24 months of age. Bowel training occurs before bladder; night bladder training usually does not occur until 3 to 5 years of age.
After examining the breast development of a 13-year-old girl, the nurse records breast and nipples appear as small mounds with areolar development evident. The appropriate stage of maturity would be
stage 2
A client with congestive heart failure presents to the emergency department with soreness from swelling of the ankles. When conducting the physical examination of this client, the nurse would require a stethoscope for which reason?
to auscultate the lungs R: The stethoscope is required to assess for the presence of fluid in the lungs, indicating that the client also has pulmonary edema, a condition that can occur in clients with congestive heart failure.
A nurse is conducting a physical examination and is percussing the gastric area of a client. What percussion tone is normally heard in this area?
tympany R: Percussion is the act of striking one object against another to produce sound. The sound waves produced by the striking action over body tissues are known as percussion tones. Tympany is a loud tone heard normally over a gastric air bubble.
